Patrick B. Murphy

Quality of Life After Total Proctocolectomy With Ileostomy or IPAA: A Systematic Review.

BACKGROUND: The standard surgical treatment for ulcerative colitis involves either a total proctocolectomy and end ileostomy or an IPAA. Both treatments result in similar control of disease but differ in terms of patient experience and daily functioning. OBJECTIVE: The aim of this systematic review was to determine whether one surgical approach was superior with regard to health-related quality of life. DATA SOURCES: An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews was performed for dates from 1978 to 2014. The search included the following terms: “inflammatory bowel disease,” “colitis,” “colectomy,” and “ileal pouch-anal anastomosis.” STUDY SELECTION: Studies were included if they reported on a comparison of total proctocolectomy and end ileostomy with an IPAA and evaluated some aspect of quality of life. INTERVENTION(S): All of the studies were systematically reviewed. No meta-analysis was performed secondary to significant heterogeneity across studies in different health-related quality-of-life measures. MAIN OUTCOME MEASURES: End points were a mixture of global, generic, and disease-specific measures of quality of life. RESULTS: Thirteen studies reporting a total of 1604 patients who underwent total proctocolectomy with ileostomy (N = 820) or IPAA (N = 783) were included for review. Neither procedure was found to be clearly superior with regard to health-related quality of life. LIMITATIONS: The conclusions of this review were limited by small study sample size, significant between-study heterogeneity, observational designs, and limited follow-up. CONCLUSIONS: Despite being limited by poor study quality, both total proctocolectomy with ileostomy and IPAA appear equivalent in terms of overall health-related quality of life. Most patients are satisfied with their choice regardless of procedure. Most of the improvement in quality of life after surgery is related to the control of disease-related symptoms. These findings indicate that both IPAA and permanent ileostomy should be discussed in detail with patients preoperatively to help them make an informed decision.

Negative pressure wound therapy use to decrease surgical nosocomial events in colorectal resections (NEPTUNE): study protocol for a randomized controlled trial

BackgroundSurgical site infections (SSIs) are the second most common form of nosocomial infection. Colorectal resections have high rates of SSIs secondary to the inherently contaminated intraluminal environment. Negative pressure wound therapy dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. No randomized control trials exist to support the use of negative pressure wound therapy following elective open colorectal resection to reduce surgical site infection.Methods/DesignIn this single-center, superiority designed prospective randomized open blinded endpoint controlled trial, patients scheduled for a colorectal resection via a laparotomy will be considered eligible. Patients undergoing laparoscopic resection will be enrolled but only randomized and included if the operation is converted to an open procedure. Exclusion criteria are patients receiving an abdominoperineal resection or a palliative procedure, as well as pregnant patients and those with an adhesive allergy. After informed consent, 300 patients will be randomized to the use of a standard adhesive gauze dressing or to a negative pressure wound device. Patients will be followed in hospital and reassessed on post-operative day 30. The primary outcome measure is SSI within the first 30 post-operative days. Secondary outcomes include the length of hospital stay, the number of return visits related to a potential or actual SSI, cost, and the need for homecare. The primary endpoint analysis follows the intention-to-treat principle.DiscussionNEPTUNE is the first randomized controlled trial to investigate the role of incisional negative pressure wound therapy in decreasing the rates of surgical site infections in the abdominal incisions of patients following an elective, open colorectal resection. This low-risk intervention may help decrease the morbidity and costs associated with the development of an SSI in our patients.Trial registrationNCT02007018 – clinicaltrials.gov; 5 December 2013

The increasing incidence of gallbladder disease in children: A 20year perspective.

OBJECTIVE The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario. STUDY DESIGN A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test. RESULTS There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%). CONCLUSIONS There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

Acute care surgery: a means for providing cost-effective, quality care for gallstone pancreatitis

BackgroundModern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC.MethodsAll patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008–May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods.ResultsIn 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of

Randomized clinical trial of negative pressure wound therapy for high-risk groin wounds in lower extremity revascularization

1162 per patient undergoing cholecystectomy, representing a 12.6% savings.The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased).ConclusionsACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

Venous Thromboembolism Prevention in Emergency General Surgery: A Review

Objective: The surgical site infection (SSI) rate in vascular surgery after groin incision for lower extremity revascularization can lead to significant morbidity and mortality. This trial was designed to study the effect of negative pressure wound therapy (NPWT) on SSI in closed groin wounds after lower extremity revascularization in patients at high risk for SSI. Methods: A single‐center, randomized, controlled trial was performed at an academic tertiary medical center. Patients with previous femoral artery surgical exposure, body mass index of >30 kg/m2 or the presence of ischemic tissue loss were classified as a high‐risk patient for SSI. All wounds were closed primarily and patients were randomized to either NPWT or standard dressing. The primary outcome of the trial was postoperative 30‐day SSI in the groin wound. The secondary outcomes included 90‐day SSI, hospital duration of stay, readmissions or reoperations for SSI, and mortality. Results: A total of 102 patients were randomized between August 2014 and December 2015. Patients were classified as at high risk owing to the presence of previous femoral artery cut down (29%), body mass index of >30 kg/m2 (39%) or presence of ischemic tissue loss (32%). Revascularization procedures performed included femoral to distal artery bypass (57%), femoral endarterectomy (18%), femoral to femoral artery crossover (17%), and other procedures (8%). The primary outcome of 30‐day SSI was 11% in NPWT group versus 19% in standard dressing group (P = .24). There was a statistically significant shorter mean duration of hospital stay in the NPWT group (6.4 days) compared with the standard group (8.9 days; P = .01). There was no difference in readmission or reoperation for SSI or mortality between the two groups. Conclusions: This study demonstrated a nonsignificant lower rate of groin SSI in high‐risk revascularization patients with NPWT compared with standard dressing. Owing to a lower than expected infection rate, the study was underpowered to detect a difference at the prespecified level. The NPWT group did show significantly shorter mean hospital duration of stay compared with the standard dressing group.

Statistical Techniques in General Surgery Literature: What Do We Need to Know?

Importance Venous thromboembolism (VTE) is the most preventable cause of morbidity and mortality in US hospitals, and approximately 2.5% of emergency general surgery (EGS) patients will be diagnosed with a VTE event. Emergency general surgery patients are at increased risk of morbidity and mortality because of the nature of acute surgical conditions and the challenges related to prophylaxis. Observations MEDLINE, Embase, and the Cochrane Database of Collected Reviews were searched from January 1, 1990, through December 31, 2015. Nearly all operatively and nonoperatively treated EGS patients have a moderate to high risk of developing a VTE, and individual risk should be assessed at admission. Pharmacologic prophylaxis in the form of unfractionated or low-molecular-weight heparin should be considered unless an absolute contraindication, such as bleeding, exists. Patients should receive the first dose at admission to the hospital, and administration should continue until discharge without missed doses. Certain patient populations, such as those with malignant tumors, may benefit from prolonged VTE prophylaxis after discharge. Mechanical prophylaxis should be considered in all patients, particularly if pharmacologic prophylaxis is contraindicated. Studies that specifically target improved adherence with VTE prophylaxis in EGS patients suggest that efficacy and quality improvement initiatives should be undertaken from a system and institutional perspective. Conclusions and Relevance Operatively and nonoperatively treated EGS patients are at a comparatively high risk of VTE. Despite gaps in existing literature with respect to this increasing patient population, successful best practices can be applied. Best practices include assessment of VTE risk, optimal prophylaxis, and physician, nurse, and patient education regarding the use of mechanical and pharmacologic VTE prophylaxis and institutional policies.

Beyond just the operating room: characterizing the complete caseload of a tertiary acute care surgery service

Effective critical appraisal of the scientific literature is an essential skill for all surgeons to remain up to date in evidence-based surgery. Through the critical appraisal process, a surgeon must determine the validity of a given study and its applicability to practice. In addition to an understanding of general research methodology, familiarity with commonly used statistical techniques is necessary to be able to determine whether study data were analyzed in an appropriate manner to answer the stated research question. Statistical knowledge is particularly important when interpreting the surgical literature, in which, due to numerous factors, observational studies predominate. Observational research relies heavily on the use of proper statistical techniques to address inherent limitations and biases. The type of statistical methodology chosen may have a significant impact on interpretation of the data and, ultimately, the conclusions drawn from the work. Therefore, a working knowledge of statistical techniques is a prerequisite for critical appraisal. As surgical literature continues to grow in both magnitude and complexity, so too does the use of statistical procedures. Previous work has described the frequency of statistical techniques used in various medical fields; however, information is limited in the surgical specialties. Furthermore, surgeons and surgical residents have been shown to be lacking in their statistical knowledge, limiting their ability to interpret studies and critically evaluate the literature. This gap in statistical literacy impairs the ability to appropriately incorporate evidence-based medicine into practice. Residency, with its designated educational time, is an ideal opportunity for surgical trainees to become

Negative-Pressure Wound Therapy for High-Risk Wounds in Lower Extremity Revascularization

BACKGROUND Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case-mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. METHODS In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. RESULTS The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. CONCLUSION Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.

Implementation of an Acute Care Surgery Service Facilitates Modern Clinical Practice Guidelines for Gallstone Pancreatitis

Lower limb revascularization is one of the most common vascular procedures performed. Regardless of approach a groin cutdown is required and surgical site infections are reported at an above average rate of 20%, significantly higher than the expected 1–4% infection rate of a clean wound (Table 1). Many experimental therapies have been unsuccessful in reducing the high rates of SSI. Negative-pressure wound therapy (NPWT) for primarily closed incisions is a relatively new concept and has garnered attention in orthopedic and cardiac surgery literature. In this chapter we review the current state of evidence for the use of NPWT following lower limb revascularization for prevention of surgical site infection.